Kasr Al Ainy, the palace built by Ahmed Ibn Al Ainy, in the years (A.D.1466-1468) by the Nile shore in the area known till now as Mouth of Khalig. This palace played an important part in the history of Cairo and Egypt which extends till now. It was used as a governmental building, a Chateau, a military hospital and a primary school till the year 1837. Mohamed Ali Pasha introduced the European military system in Egypt and wanted to provide it with the medical aid. He assigned Dr. Clot Bey, from France to establish a medical school in Abu Za'abal to prepare doctors for the army in the year 1827. It was after 10 years that the medical school was transferred to Kasr Al Ainy as a medical school and hospital. Kasr Al Ainy witnessed all the changes that occurred in Egypt till now, serving all the Egyptians and non-Egyptians.

Celebrating the first online issue of Kasr Al Ainy Medical Journal, published by Wolter Kluwer, the team that participated in this work is excited and anxious, hoping that this new journal can meet some of their expectations.

One of the most famous proverbs said about Kasr Al Ainy is as follows: 'We don't live in Kasr Al Ainy, it lives inside us'. Kasr Al Ainy is not just a health or an educational institute; it stands there through centuries in its position as a part of our history and heritage, as important as the pyramids and the sphinx. I do not really believe that an Egyptian does not know about Kasr Al Ainy, and those who lived in or worked in Kasr Al Ainy became fascinated with the soul of the great building and the great men who had been there through times.

In the year A.H. 871 (A.D. 1466-1468), a grand palace was built by El Moquerr El Shehaby Ahmed Ibn Al Ainy, 'The Grand Master of the Horse' and the son of the daughter of the Sultan Abu Sayed Seyfeddin Khoshquadam El Nassry el Moayedy, of the Circassian dynasty of Mamlooks. When the construction of the palace was completed, the Sultan went there for a visit and was very pleased to look all around the Nile.

Kasr Al Ainy was one of the very few governmental buildings on the Nile near Cairo and was therefore made a convenient resting place for the high officials on their river journey to and from Alexandria.

When Casten Niebahr (1733-1815) made a map of Cairo, he showed Kasr Al Ainy as standing in a large, quiet, open area extending to the mouth of Khalig and described it as 'a large building surmounted by a beautiful cupola'.

This was later also referred to by the French in their maps or books as the 'Chateau' or 'ferme' of Ibrahim Bey.

During the short French occupation, they turned Kasr Al Ainy into a military hospital and apparently fortified it by a surrounding wall. The map mentioned it as 'Hopital Mailitaire, Qasr el Ainy, ou ferme d'Ibrahym Bey'. In 1799, they built a bridge between Kasr Al Ainy and Roda Island and another one to connect Roda with Giza.

In 1801, convalescents from plague lazaretto at Bulaq were sent to Kasr Al Ainy until they were moved to Rosetta on the arrival of the English Army.

On September 1799, General Kleber held a reception at Kasr Al Ainy for the higher class natives with presentation of cavalry and infantry. The next June, he was stabbed by Soliman El Halaby in the garden in which Shepheard's hotel now exists. His funeral procession started from Ezbakya and stopped at Kasr Al Ainy, where his coffin was put on a raised ground covered with earth and was surrounded by a railing. This coffin was removed and sent home with the retreating French army.

Mohamed Ali Pasha was the first Governor of Egypt after the French occupation.

After the massacre of the Mamluks, in 1811, a military college was established in Aswan in 1816. From this college, youths were transferred to the army, and it was found necessary to open a school for the college at Kasr Al Ainy. There were Circassian, Georgian, Turk, Arnaout, Armenian and Greek students, but no Egyptian students. The teaching language was Turkish, but the students were taught a little in Persian, Arabic and Italian by their professors.

The primary school lasted from July 1825 until January 1837, when it yielded its place to the Medical School. The primary school of Kasr Al Ainy comprised 800 boys, varying in age from 10 to 15 years, and a library that contained about 15 000 French and Italian books.

When it was determined to introduce the military system of Europe into Egypt, the French officers were employed to organize the army. There was a necessity to provide some medical aid for the troops. Pasha quickly recognized its importance. Moreover, a second cause compelled him about the same time to establish not only hospitals and a Medical School but also a Sanitary Department for the plague that broke out in Cairo and Turkey in 1824 and lingered about the Levant until the great epidemic of 1834 and the following years.

In the year 1825, Clot Bey arrived from France and was appointed Physician and Surgeon in Chief to the new army. He was followed by 154 European medical officers and apothecaries, mostly Italians and Frenchmen. It was at this time that the 25 000 soldiers at Abu Za'abal in the desert behind Abbasiya, and this camp hospital became attached on the site of a former Cavalry Barrack.

In 1827, Clot Bey had to establish at Abu Za'abal a Medical School so as to furnish surgeons and aposthecaries for the army. He himself became director of the school, and professor of surgery, and in 10 years he produced 450 medical officers for the army and navy.

Moreover, in 1837, two secondary Medical Schools were started, one at Alexandria and the other at Aleppo, 'for the improvement of the practical instruction of pupils who leave the school at Abu Za'abal'.

Although the Medical School was at Abu Za'abal, the annual examination was held with great ceremony, and 'all the high officials, the Ulmas, the consuls and distinguished visitors were invited', but later this custom was given up, to Clot Bey's regret.

In November 1832, 5 years after the formation of the Medical School, 12 selected Egyptian students wearing turbans and flowing robes were taken to Paris by Clot Bey and were formally examined by 14 well-known medical professors.

Clot Bey tried to get the school to Roda Island or Alexandria, but did not succeed until 1837 when both the hospital and the Medical School were transferred from Abu Za'abal to Kasr Al Ainy, for the desert camp had been abolished and the troops were all fighting in Syria. Clot Bey mentioned at that time that Kasr Al Ainy consisted of four ranges of buildings in a square, 64 spacious apartments of 40 beds, each of two stories, with a separate building for the pharmacy, the chemical laboratory, the museum of physics and natural history, amphitheatre, baths and kitchens.

The medical course at this time was for a duration of 5 years; the ages of the students ranged between 20 and 25 years and consisted of three groups of 100 each; they wore military uniform and were fed, dressed and lodged at the expense of the Government. They also received pocket money, beginning at 40 piasters per month.

Some of the original prejudices that had to be overcome in including Moslems in the dissection of dead bodies were immense, and the dissecting room had to be surrounded by guards, who were kept ignorant of what they were guarding. Clot Bey began by dissecting a dog, 'not even a Moslem's dog, but a Jew's or a Christian's dog'. Later, he got permission to use the bodies of black slaves and was allowed to bring skulls and bones from disused cemeteries to his lecture room, although the Ulma had begun by decreeing that dissection of a human body was against the tenets of Moslem's faith.

Eventually, steady perseverance overcame all difficulties, and the students 'became so interested that they would take home portions of the body to study'. This was a decided triumph in a country where a mother had been known to cut off the forefinger of her child's right hand to prevent his being able to write, rather than have him clothed, taught, fed and paid in the Government Schools.

Attached to the Medical School, there was also a section of veterinary medicine with a 5-year-course, and a school for midwives, mostly Negress and Abyssinians, which was opened in 1832.

To improve the clinical teaching, interesting cases were sent to Kasr Al Ainy from civil and military hospitals of the provinces, and the fame of the staff reached to Greece, Syria and Arabia, and patients from these countries came every year to be treated in Cairo. Post-mortem examination was also introduced during the same period. Clot Bey could boast that 20 000 books related to medical sciences had been issued in Bulaq Printing Press, all translated from French to Arabic. Copies of these works were sent to Constantinople, Algiers, Tunis, Morocco, Persia and Syria.

Of all the Europeans attached to Egypt during the first half of the 19th century, no one has been as fortunate as Clot Bey (1793-1868) in impressing upon the modern Egypt the durability of his work. One of the greatest services were the introduction of vaccination throughout the country by means of 2500 barbers who had to first be trained for the work.

Despite all this great work, Clot Bey had his enemies and detractors, and among the best known was Hamont, the head of the Veterinary college, besides Sheikhs, Ulemas, parents, officers of the army and navy, and all agreed that it was useless to try to turn Egyptians into doctors. All these were against him except Mohammed Ali Pasha. One little story shows how fanatical those early times were. On one occasion, two of the foreign doctors, dressed in European clothes, were set upon by a mob near Saiyda Zeinab mosque, and beaten and ill-treated as they were harmlessly passing by. When they arrived in tatters at the Citadel, Clot Bey, rushed in a fury to Pasha and vowed that he and all his assistants would leave to Europe. Mohammed Ali told him plainly he could not restrain the hatred of his people for everything European and advised him and others to dress in future as Mamluks. This was followed and no further annoyance took place. There were some famous pictures; one of them [Figure 1] shows Clot Bey inoculating himself with pus from a plague bubo in Ezbakiya Hospital, on 15 March 1835, and professors, students and visitors, all dressed in turbans and robes.

Figure 1: Clot Bey inoculating himself with pus from a plague bubo in Ezbakiya hospital on March 15, 1835

After the death of Mohammed Ali, Abbas I succeeded him, but he discouraged all French enterprises and stopped most educational progress during the 5 years of his reign. The Medical School suffered like others, and Clot Bey retired to France in despair.

Abbas I then substituted German professors for French and removed the advanced Egyptian students from Paris to Munich. He was fortunate enough to engage Wilhelm Griesinger (1817-1868), the professor of Pathology at Kiel, to fill the triple post of Director of Kasr Al Ainy, President of the Sanitary Council and personal physician to the Viceroy.

Griesinger was delighted at the prospect of exploring the diseases of an unknown country. He reached Cairo in June 1850, accompanied by his former student Dr. Theodore Bilharz, who came as his assistant, and by Dr. Alexander Reyer, who was elected as his surgical colleague in the hospital and school. The name of Theodore Bilharz is even better known to his generation than that of Griesinger, after his discovery of Distoma haematobium (later known as Schistosoma haematobium).

Abbas I was not contented with his German advisors, and for a brief duration Kasr Al Ainy was placed under Italian influence. In the year 1854, Dr. Raggi and Dr. Ranzi arrived from Florence to fill the chairs of medicine and surgery in Cairo. However, in the following year, Said Pasha suppressed the Medical School, on the ground that it had been a trade there to deliver fraudulent certificates of ill-health as exemption from military service. The medical students were drafted into the army, to the great grief of Clot Bey who hurried back from France on hearing the death of Abbas I. 'I have seen in one day the destruction of the labors of my whole life' he cried. The wheel of fortune soon turned, and Said Pasha discovered he could not do without medical students; therefore, in September 1856, he reopened the Medical School in the presence of Clot Bey, who was compelled to finally leave Egypt in 1858 for health reasons.

The School of midwives in Kasr Al Ainy consisted of 30 students who underwent a 5-year-course, and an attempt was made to provide them with clinical experience by sending pregnant women to the maternity wards, by giving any woman who would come voluntarily a present of 40 piasters on leaving, and by paying the midwives for any case they got to the hospital.

In 1876, there were 18 native teachers and 195 students; of whom, 175 were residents, bound at the end of the curriculum to enter the army or the sanitary service, and 20 were volunteers who paid nothing for their instruction and were free to follow private practice if they wished.

Kasr Al Ainy Hospital was utilized for cholera patients during the epidemics of 1865 and 1883, and it was during the later year that Dr. Koch discovered the comma-shaped bacillus in Alexandria.

Dr. Fleming Sandwith was the first English man who had ever entered the medical service of the Egyptian Government. He mentioned that, in addition to the public health in Egypt, he had to control 23 Government hospitals, of which Kasr Al Ainy was by far the best equipped, as it was obviously the most important in the whole country.

During these days the whole situation of the hospital began to deteriorate badly and it was not surprising that hardly any single soul ever went to hospital of his own free will, the exception being blind beggars who were driven there by poverty. The people firmly believed that the hospital was a prelude to the cemetery and that the sick were beaten and robbed by the attendants, and then poisoned by the doctors. Needless to say, no respectable woman ever applied to the hospital for advice, and no parent ever left his child in the wards for treatment. Six Egyptian professors of the school used to pay daily visits to the hospital wards. These wards have been divided into sections of surgery, medicine, ophthalmia, skin and venereal diseases, prostitutes, as well as sections for women as a forlorn hope for operative midwifery.

In the school there were also teachers of physiology, forensic medicine, anatomy, chemistry, material medica and physics, without hospital beds. Ninety male students, representing four out of six classes, were supposed to 'walk' the hospital, but they were not allowed to enter the female wards where there were 30 student midwives.

Injuries and diseases of the most trifling character were sent by the police and had to be admitted. There was no nursing; the attendants were entirely of worn-out old soldiers, who had been dismissed from the army, with no moral control over the patients. There was systemic absence of clinical teaching, note taking, temperature records, urine testing or thorough physical examination. The medical diagnosis seldom advanced beyond 'anemia' or 'gastric catarrh'. Antiseptics were absent in operating rooms, and there was fear of anaesthetics, that most major operations, including lithotomy, were performed without them. There was a heap of surgical instruments, laid neglected in need of repair, and no one could fix them.

Prisoners were not guarded and therefore had to wear heavy chains around their ankles all time.

Sandwith began to remove without delay all abuses, which needed prompt redress. He chosed H. Milton to assist him in his task. Because of lack of money during these days, the improvement made by them was very limited. However, all workers in the hospital had to respect the aseptic laws.

Dr. Milton devoted a great part of his time for developing wards for respectable native women, where the number of beds gradually rose from nil to 130, and many new operations were performed in Cairo by him. Some of the native midwives and girl students became most excellent dressers and assistants and nursed special cases with fidelity and dexterity. However, they needed to be trained more for the routine nursing of the uninterested cases.

Tawfik Pasha, in 1888, consented to allow two English sisters to be imported to superintend the female wards. Unfortunately, after few months, one of them returned home after a dangerous attack of typhoid fever, and the other died of the same disease. When Milton himself had the same disease, the public works department decided to build a house for the sisters in the hospital precincts on a part of the old botanical gardens. This encouraged more English sisters to come, who were also allowed to nurse the male wards.

In the outpatient department, started in 1885 by Milton and later by Dr. Sandwith, the number of patients mounted up to 250 every day. Therefore, their diseases had to be divided into various sections. Post-mortem room was built by the Ministry of Public Instruction, instead of having the work performed in the old bathroom of the hospital. Fortunately, at that time the Director of the School, Issa Pasha Hamdi, who was also the private physician of the Khedive, had sufficient influence to get new buildings in place of the tumble-down structures that were a disgrace to the Government. However, a great interest in the welfare of the School was taken after the fortunate appointment of Yakoub Artin Pasha in 1884 as Under Secretary of Public Instruction.

In 1896, the Government decided to spend about £27 000 on reconstruction of the hospital. The walls were oil painted, their corners rounded, windows and doors improved, and several small observation wards added. Two operating theatres were constructed and the roof was made solid enough to be used as a promenade for women patients and nurses.

European teachers were appointed to the chairs of pathology and bacteriology, chemistry and physiology, and the annual examinations were gradually made more serious. A splendid bacteriological laboratory was built, and physiological and histological laboratories and stables for research animals quickly followed. The students were encouraged to study English as far as time allowed, but instructions had to be continued in Arabic.

Since the beginning of the Medical School, all students received a small salary, but after these new arrangements, many received no pay and others had to pay fees; it was settled that, in future, no students are to be paid for the privilege of being educated in medicine by the Government.

The new staff members began their work in October 1898, and the better working of the hospital and school had justified the changes made. Since that day, instruction to the students and the books provided were all in English. The library was removed to a spacious room, where it was catalogued and placed under the control of a librarian, who also gave English lessons to the students.

There was improvement in the diet tables, pharmacopoeia, nursing and system of hot water. A house had been built for the director, and, by the end of 1901, a nursery for the care of foundlings brought to the hospital was opened on the North side of the hospital. Electric light was introduced to some of the school buildings, a student's clubroom was opened and they were provided with a football ground. There had also been marked improvement in the intelligence, healthy bearing and social standing of the modern student.

It must be remembered that extensive reforms in the school and hospital could not have been carried out without the loyal support of many officials of the Egyptian Government, including the Director General of the Sanitary Department, and the Secretary General of the Ministry of Public instruction [1].

By the beginning of the 20th century, there had been sustained improvement. Local doctors and professors began to gain control on the hospital and school of medicine. Some were greatly talented in their work with excellent training in Europe. They continued teaching and training of medical students, with clinical rounds for the discussion of cases, scientific meetings, seminars and conferences; further, scientific teams made many trips for medical surveys and treatment all over the country.

The neighbourhood around Kasr Al Ainy was not the same, there was explosion in surrounding areas and it became crowded with houses and streets. Kasr Al Ainy old building was still standing near Fom El Khalig, and there was necessity to build another building to assist with the old one to adapt for the increasing numbers of students and patients for both school and hospital.

In 1927, King Foud laid the foundation of a new Kasr Al Ainy Hospital and school. This building was established on the Manial El Roda parallel to the old Kasr Al Ainy and extending to the North end of the island. Both have been connected by two bridges. The new building included the academic sections, as well as a great new hospital with large well-ventilated wards, outpatient clinics, play grounds and gardens, and the most amazing thing is that it adopted the name New Kasr Al Ainy.

Later, with the increase in the number of hospitals added to Kasr Al Ainy and increase in the number of medical students 'particularly after the Governmental Universities had been made free of charge' it has been decided to get rid of the old palace, which was not in a good condition, and was replaced with two hospital buildings, one for the Medicine Departments and the other which has been given the name 'French Kasr Al Ainy' was presented as a gift from the France to the Egyptian Government.

Kasr Al Ainy Medical School is now one of the largest and most prestigious medical schools in Africa, Middle East and the Arab Region. It includes 36 departments, 44 specialized units, 5500 beds over 11 hospitals, which serve approximately more than two million patients a year, 3347 staff members, 9687 undergraduate and 8856 postgraduate students. Egypt has a wealth of research capacity. A study conducted in Egypt showed that nearly all (96.7%) of the research is published. Most (89.2%) of the results are published in local journals, 7.3% in international and 3.55% in regional journals.

One day I was thinking, 'The professor who didn't help his student to be better than himself did not succeed'. As the wheels are continuously moving, we look forward to the best for our junior staff and students, on whom we rely for treating disease and for the improvement of our country.

This historical part has been adapted from:

F.M. Sandwith, K.D., F.R.C.P. (1853-1918) 'Senior Physician, Professor of Medicine at Kasr Al Ainy Hospital and School, and member of the Egyptian Institute'. Records of the Egyptian Government, Faculty of Medicine, 1927; Cairo: Government Press.